Falls with No Loss of Consciousness

Differential Diagnosis

Common Diagnoses

  • Orthostatic Hypotension
  • Parkinson’s Disease
  • Iatrogenic (e.g. Phenothiazines, Hypoglycaemics, Tricyclics and Hypotensives)
  • Postural Instability (Osteoarthritis, Muscular Weakness and General Frailty)
  • Any Acute Illness (e.g. Sepsis, CVA)

Occasional Diagnoses

  • Peripheral Neuropathy (Various Causes)
  • Lack of Concentration (Tripping over Mats, etc.)
  • Visual Disturbance
  • Acute Alcohol Intoxication and Chronic Alcohol Misuse 
  • Cardiac Arrhythmias
  • Any Cause of Vertigo (e.g. Vestibular Neuritis, Ménière’s Disease) or Non-specific Dizziness (e.g. Anaemia)
  • Hypoglycaemic Episodes
  • Dementia

Rare Diagnoses

  • Hydrocephalus
  • Third Ventricular Tumour
  • Diabetic Autonomic Neuropathy
  • Aortic Stenosis
  • Painless (‘Silent’) Myocardial Infarction

Ready Reckoner

Key distinguishing features of the most common diagnoses

Orthostatic HypotensionParkinson’s DiseaseIatrogenicPostural InstabilityAcute Illnes
Joint StiffnessNoNoNoPossibleNo
On Standing upYesPossiblePossiblePossibleYes
On Turning HeadNoNoNoNoPossible

Possible Investigations

Likely:Urinalysis, FBC.

Possible:TFT, U&E, B12 and folate, fasting glucose or HbA1c, serum electrophoresis, vitamin D, LFT, ECG (or 24 h ECG/event monitor).

Small Print:CT scan, echocardiography.

  • Urinalysis for glucose may reveal underlying diabetes: A major cause of autonomic or peripheral neuropathy – or evidence of UTI.
  • FBC: Anaemia will exacerbate any cause of postural hypotension, or may itself cause dizziness. Sepsis is suggested by a raised WCC. A high MCV may be a useful pointer to alcohol misuse, B12 or folate deficiency, or hypothyroidism.
  • TFT: Hypothyroidism is common in the elderly and develops insidiously.
  • Fasting glucose or HbA1c: To confirm or detect diabetes.
  • U&E, B12 and folate, serum electrophroresis: Renal failure, B12/folate deficiency or myeloma may cause a peripheral neuropathy.
  • Vitamin D: Deficiency may cause muscular weakness.
  • LFT: For evidence (γGT) of alcohol misuse.
  • ECG or 24 h ECG/event monitor is useful to identify an arrhythmia, conduction defect or MI.
  • CT scanning (e.g. for tumours or hydrocephalus) or echocardiography (for aortic stenosis) may be arranged by the specialist after referral.

Top Tips

  • Failure to observe the patient’s gait may mean that significant diagnoses, such as Parkinson’s disease, are missed.
  • Recurrent falls in the elderly are often caused by a combination of factors, such as failing vision, poor lighting and trip hazards at home. A home assessment may give valuable clues.
  • In the acute situation, management may depend more upon the ability of the patient to remain safely at home (e.g. social support) rather than the precise diagnosis.
  • Don’t underestimate the importance of what you prescribe in causing morbidity. Attempt to reduce polypharmacy and review therapy regularly.
  • Recurrent falls in the frail elderly are a real concern with the prospect of significant injury and recurrent admission. They can also be fiendishly difficult to pin down and resolve – so use your local multidisciplinary falls team if you have one.

Red Flags

  • In dealing with this problem, don’t forget to look for cause and effect – the aetiology of the falls and any significant injuries sustained.
  • Sudden onset of falls in the previously well elderly patient is likely to represent acute pathology – have a low threshold for investigation or admission.
  • Gradual onset of recurrent falls is often multifactorial in the elderly; in younger patients, specific underlying disease is more likely, so refer for investigation.
  • Evidence of injury (e.g. bruises or fractures) and multiple attendance slips from A&E department indicate either a very frail, vulnerable elderly person or significant underlying illness.
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